The Uninsured: A Primer - Key Facts about Health Insurance and the Uninsured Under the Affordable Care Act

In the past, gaps in the public insurance system and lack of access to affordable private coverage left millions without health insurance, and the number of uninsured Americans grew over time, particularly during economic downturns. By 2013, the year before the major coverage provisions of the Affordable Care Act (ACA) went into effect, more than 44 million nonelderly individuals lacked coverage.1

Under the ACA, as of 2014, Medicaid coverage has expanded to nearly all adults with incomes at or below 138% of poverty in states that have adopted the expansion, and tax credits are available for people with incomes up to 400% of poverty who purchase coverage through a health insurance marketplace. Millions of people have enrolled in these new coverage options, and the uninsured rate has dropped to a historic low. Coverage gains were particularly large among low-income people living in states that expanded Medicaid.

Still, millions of people—27.6 million nonelderly individuals as of 2016— remain without coverage.2 Those most at risk of being uninsured include low-income individuals, adults, and people of color. Cost continues to pose a major barrier to coverage with nearly half (45%) of nonelderly uninsured adults in 2016 saying that they remained uninsured because the cost of coverage was too high.3

Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured people are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected. While the safety net of public hospitals, community clinics and health centers, and local providers provide a crucial health care safety net for uninsured people, it does not close the access gap for the uninsured.

For many uninsured people, the costs of health insurance and medical care are weighed against equally essential needs, like housing, food, and transportation to work, and many uninsured adults report being very or moderately worried about paying basic monthly expenses such as rent or other housing costs and normal monthly bills.4 When uninsured people use health care, they may be charged for the full cost of that care (versus insurers, who negotiate discounts) and often face difficulty paying medical bills and potential medical debt. Providers absorb some of the cost of care for the uninsured, and while uncompensated care funds cover some of those costs, these funds do not fully offset the cost of care for the uninsured.

Under current law, nearly half (47%) of the remaining uninsured are outside the reach of the ACA either because their state did not expand Medicaid, they are subject to immigrant eligibility restrictions, or their income makes them ineligible for financial assistance.5 The remainder are eligible for assistance under the law but may still struggle with affordability and knowledge of options and require targeted outreach to help them gain coverage. However, proposed policies to change the structure of the Medicaid program or cut back subsidies for Marketplace coverage may pose a challenge to further reducing the number of uninsured and may threaten coverage gains seen in recent years. On the other hand, state action to take up the ACA Medicaid expansion could make more people eligible for affordable coverage. The outcome of current debate over health coverage policy in the United States has substantial implications for people’s coverage, access, and overall health and well-being.